A novel virtual reality-based simulator for training in LLETZ procedures: Development and preliminary validation

A novel virtual reality-based simulator for training in LLETZ procedures: Development and preliminary validation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A novel virtual reality-based simulator for training in LLETZ procedures: Development and preliminary validation Anne Cathrine Scherer-Quenzer, Ute Trapp, Benjamin Meyer, Quirin Notz, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8882607/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Cervical intraepithelial neoplasia is commonly treated by large loop excision of the transformation zone (LLETZ), a technically demanding procedure associated with risks such as incomplete excision and cervical insufficiency. In view of patient safety and ethical concerns regarding “learning by doing,” simulation-based training is increasingly important in gynecologic education. To address the lack of a dedicated LLETZ simulator, we developed a virtual reality (VR) system specifically for LLETZ training, conceived as an open-source platform. Methods The central achievement of this work is a VR environment that provides a colposcopic view of the cervix, real-time tissue cutting with generation of a separate, inspectable cone specimen, and automated performance metrics. Senior consultants were invited to test the simulator to evaluate its face and content validity and its overall usefulness. Subsequently they completed a 14-item validation questionnaire and the 16-item Post-Study System Usability Questionnaire Short (PSSUQ-Short). Results Face validity was rated favourably for target anatomy and overall realism, whereas instrument handling and tissue response received more moderate scores. Content validity and educational value were judged positively, with high ratings for understanding procedural workflow, hand–eye coordination and cutting precision, and willingness to integrate the simulator into structured curricula. Usability ratings were likewise favourable across all PSSUQ domains. Conclusion This pilot study demonstrates the successful design of a VR-based LLETZ simulator that is feasible and educationally meaningful for training gynecology residents, and provides a promising foundation for further open development and optimisation. virtual reality LLETZ simulation gynecology surgery training Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Cervical cancer is the fourth most common cancer in women worldwide [ 1 ]. The majority of cases originate from precancerous changes in cervical epithelial cells, known as cervical intraepithelial neoplasia (CIN) [ 2 ]. When a high-grade squamous intraepithelial lesion (HSIL) is detected, surgical excision is generally recommended to prevent progression to invasive carcinoma. Among the available excision and ablation techniques, large loop excision of the transformation zone (LLETZ) represents the standard of care for treating HSIL and other high-grade dysplastic lesions [ 3 – 6 ]. In Germany alone, more than 100,000 LLETZ procedures are performed annually [ 7 ]. Although LLETZ is a routine and well-established procedure, it remains technically challenging and carries notable risks such as incomplete excision, bleeding, or cervical insufficiency in subsequent pregnancies [ 8 – 10 ]. Traditional surgical education follows the principle of “learning by doing,” where residents acquire procedural skills directly on patients under supervision. Given these risks, such a training model raises important ethical and patient safety concerns [ 11 ]. Therefore, there is a growing consensus that modern gynecologic training should incorporate simulation-based learning to improve surgical competence in a controlled and risk-free environment [ 12 ]. Simulation-based education enables repetitive practice without patient risk, facilitates objective performance assessment, and allows exposure to rare or critical situations that may not occur frequently in clinical settings [ 13 ]. In gynecology, various forms of simulation have been introduced, ranging from simple low-fidelity models to advanced computer-based systems [ 14 – 16 ]. Traditional physical simulators for LLETZ—often self-constructed or commercially available cervical models—have been used to train visualization and excision techniques [ 17 ]. However, these models typically require continuous instructor supervision, are time-consuming to set up, and can be costly to maintain. Moreover, they lack standardized feedback mechanisms and are difficult to scale for larger educational programs [ 13 , 18 , 19 ]. Recent advances in digital technology have made virtual reality (VR) an attractive alternative for medical training. VR-based simulators provide immersive, interactive environments that allow trainees to perform procedures repeatedly and receive automated feedback without direct supervision [ 20 , 21 ]. VR has already been shown to shorten learning curves and enhance skill acquisition in various surgical disciplines, including laparoscopy and orthopedics [ 22 , 23 ], However, to date, no dedicated VR simulator for the LLETZ procedure has been reported. Moreover, no open-source solution currently exists that enables reproducible training scenarios, anonymized data export, and asynchronous expert evaluation for LLETZ training. To address this gap, we developed a novel virtual reality-based simulator specifically designed for training in LLETZ procedures. The system integrates realistic colposcopic visualization, real-time tissue cutting, and automated performance analysis. Senior consultants were invited to test the simulator to evaluate its face and content validity and its overall usefulness. This work represents an important step toward establishing an accessible, standardized, and objective VR training platform for cervical excision procedures in gynecology. Materials and methods The following section intentionally provides a detailed technical description. It explains the design process of the VR simulator, the tools which have been used to implement it, technical challenges which have been faced, how they have been addressed during the development and how the gathered training data is recorded to generate detailed performance reports for each participant. These contribute to both, system fidelity and measurement precision, which are central to evaluating the validity of VR-based surgical training tools. Design and Development Process of the VR-simulator The simulator was developed using an iterative, user-centered design process, with repeated formative evaluations conducted together with senior gynecological consultants and physicians in training. Representative descriptions of typical end users, user personas, were formulated to consider the goals, desires and technical experience of the expected training participant. With the personas in mind, a short tutorial and usability tests have been created. During the usability test sessions, feedback from these expert users informed successive refinements of interaction design, onboarding, ergonomics, and performance assessment throughout development. Software and platform information The VR application itself was created in the Unity Engine (version 6.3) and incorporates several 3D assets that were modeled and textured in Blender (version 4.5.4 LTS) before being imported into Unity. Unity is a software which is used to develop immersive games and interactive simulations. The application source code is hosted in a public GitLab repository [ 24 ] and released under an MIT-style open-source license. The application runs on Windows 11, Android and any OpenXR [ 25 ] capable VR-Headset. Design of digital assets As an initial step, Blender software (version 4.5.4 LTS) was utilized, to construct a simplified three-dimensional model representing a colposcope and the surgical environment (Fig. 1 ). All instruments (colposcope, speculum, electrosurgical loop, smoke extractor) were created with clinically accurate dimensions based on specifications of equipment currently deployed at University Hospital Würzburg. The colposcope model replicates optical geometry and working distance of clinical devices. The electrosurgical loop was modeled to match commonly used LLETZ loop sizes (typically 15–20 mm width and 10–15 mm depth). Given the open-source nature and potential for uncontrolled distribution, anatomical representations were deliberately abstracted: the cervix is represented as a cylinder and the portio as a torus (Fig. 2 ). Realistic colposcopic simulation and visualization To replicate optical characteristics relevant for stereoscopic depth perception, working distance (~ 20 cm from virtual headset camera to cervix, derived from clinical practice) and interpupillary distance (IPD) were derived from technical specifications of a clinical colposcope in use at University Hospital Würzburg. Because Unity does not provide a general, direct low-level control of the stereo view matrix from the VR camera rig for IPD changes in all OpenXR configurations, IPD adjustment was implemented by calculating a scaling factor: colposcope-derived IPD divided by the headset-native camera IPD (configured by Unity/OpenXR per device). The camera rig was then scaled horizontally along the x-axis by this factor, enabling stereoscopic alignment without directly modifying the view matrix. In addition, three discrete zoom levels (1×, 2×, 3×) replicate common colposcope magnification steps. Interaction design and tracking accuracy considerations Instrument interaction is controller-based and designed to support repeated practice without instructor supervision. Collision handling (i.e. between instrument and tissue) and bound checks were implemented to prevent physically implausible tool positions from silently corrupting spatial learning by providing extensive feedback to the user (see “Ergonomic and safety design” below). The tracking accuracy of the employed head-mounted display is sufficient for the spatial requirements of LLETZ simulation. The Valve Index provides positional accuracy in the millimeter range [ 26 ], which is adequate given an excision depth of approximately 8–10 mm and an excision width of about 2 cm. This level of accuracy was confirmed by our own measurements. Additional measurements conducted with a Meta Quest 3 showed slightly lower, yet still sufficient, positional accuracy, remaining within the millimeter range required for the task. Real-time tissue cutting engine The cutting algorithm was designed to enable stable real-time excision across complex cervical geometry, including the clinically relevant convex–concave–convex transition at the external cervical os, while allowing continuous depth measurements and the generation of both the excised specimen and the residual cervix. Real-time cutting proved to be the most technically demanding component of the simulator; therefore, three algorithmic approaches were iteratively explored. An initial prototype based on constrained Delaunay triangulation [ 27 ] was limited by the computational complexity of reassembling mesh topology after cutting and showed instability when crossing the cervical os transition, resulting in mesh artifacts and topological errors [ 28 ]. A subsequent constructive solid geometry (CSG) approach improved geometric stability but raised concerns regarding long-term library maintenance, borderline performance for complex excision shapes, and limited maintainability of the implementation [ 29 ]. The current solution employs signed distance fields (SDF) with ray marching, which provides robust handling of arbitrary cutting paths, maintains real-time performance, and supports quantitative measurements (e.g., depth and volume) required for automated feedback. In this implementation, both the surgical instrument and the approximated cervical tissue model are represented using an SDF ray-marching approach. Conceptually, the SDF represents tissue as a mathematical function rather than a surface mesh, which avoids topological instability during cutting and enables robust Boolean operations. During the procedure, the loop pose is recorded continuously; the resulting cutting volume is then applied as a Boolean subtraction on the SDF to generate (1) the excised tissue specimen and (2) the residual cervical representation. This approach further enables computation of quantitative metrics such as resection depth progression and excised volume. Data logging, analytics, and automated scoring The simulator continuously captures clinically relevant parameters, including cutting depth progression sampled at 60 Hz during active cutting, tissue contact patterns (duration/frequency of loop contact with the portio versus the cylindrical cervix representation treated as a critical error region), and loop velocity to identify rushed or hesitant technique. To support margin assessment and cone-shape verification, multi-angle screenshots of the excised tissue are captured automatically from standardized viewpoints. Additionally, post-procedure 3D visualization of residual versus excised tissue is provided for debriefing and structured feedback discussions. In addition, an automated LLETZ/LEEP adequacy score is computed following the methodology described by Takacs et al. [ 30 ]. These standardized outputs are intended to complement, not replace, expert instructor judgment (Fig. 3 ). Persistence, export, and user interface (UI) design A hybrid persistence strategy balances performance and accessibility: session metadata, metrics, and scoring are stored in a SQLite database (and can be exported as an Excel file for further analysis); and screenshots as PNG files. SQLite was chosen as it is a fast, small, widely-deployed and cross-platform database engine which does not rely on a separate server process but directly reads and writes to disk. This design enables longitudinal skill tracking across sessions and supports reconstruction of procedures for detailed review. Preparation and detailed post-operative data review are presented primarily on desktop displays to reduce discomfort during prolonged analysis of graphs and numerical information. Procedural cues required during the excision remain available within VR using world-space UI elements. Unity’s UI Toolkit world-space workflows were leveraged for the standalone-compatible interface components (Unity documentation) [ 31 ]. System enhancements A speculum was added to improve anatomical context, and smoke generation with extraction visualization was implemented to enhance realism during electrosurgical cutting. To maximize accessibility in clinical environments, the system supports standalone operation on compatible headsets (e.g., Meta Quest). Users begin in a virtual waiting room displaying preparatory information (procedure overview, learning objectives, controller instructions). This additional scene was introduced in response to early expert feedback, as initial versions that placed users directly in the operating room led to spatial disorientation and reduced task readiness. After completion, performance data can be uploaded to a Nextcloud instance to enable asynchronous expert evaluation. Ergonomic and safety design To compensate for missing true haptic feedback, the simulator provides layered feedback: (1) differentiated controller vibration patterns (gentle vibration for correct portio contact; strong distinct pattern for critical error zones), (2) audio cues during energized cutting, and zoom change of the colposcope and (3) visual warnings including critical error notifications. For severe safety violations (e.g., activated loop contacting critical tissue regions or excessive depth beyond a predefined threshold), the simulation terminates immediately to reinforce safety learning. Equipment Our system consists of a VR setup built around the Valve Index® headset (Valve Corporation, Bellevue, USA), which provides tracking for both the headset and the controllers. The workstation driving the simulation is a custom-built PC (Gigabyte B650 Eagle AX motherboard) equipped with an AMD Ryzen 5 7600X processor, ASUS Dual GeForce RTX 5060 Ti 16 GB OC graphics card, and 32 GB DDR5 RAM. Evaluation Participants Seven consultant gynecologists from the Department of Obstetrics and Gynecology at the University Hospital Würzburg voluntarily participated in the study. Each of them had at least 5 years of expert experience in the field of colposcopic surgery. None of the participants had prior contact to the virtual reality simulator and none of them had been involved in the process of development. Each participant received a brief introduction to the VR hardware and controls and performed five standardized LLETZ procedures on a virtual cervix with a predefined high-grade lesion. Participants were asked to complete the excision as they would in clinical practice. After finishing the procedure and reviewing the automated performance metrics, they removed the headset and immediately completed the validation questionnaire followed by the PSSUQ. Questionnaires The validation questionnaire comprised 14 closed-ended items and two open-ended questions evaluating the virtual reality (VR) simulator for Large Loop Excision of the Transformation Zone (LLETZ). The first five statements assessed the face validity of the simulator, focusing on the realism of anatomical structures, instrument handling, and tissue response. The next four statements addressed the content validity, evaluating the simulator’s usefulness for understanding procedural workflow and training relevant technical and perceptual skills. Subsequently, five statements explored the educational value and applicability of the simulator in clinical training. All items were rated on a five-point Likert scale ranging from 1 (“not realistic/useful”) to 5 (“very realistic/useful”). Finally, participants were invited to provide open-ended comments on the most realistic or helpful aspects of the simulation and to suggest improvements for future versions. The Post-Study System Usability Questionnaire Short (PSSUQ-Short) with 16 items was administered to evaluate system usability. The questionnaire covers the domains system usefulness (items 1–6), information quality (items 7–12) and interface quality (items 13–16). All items were rated on a scale ranging from 1 (“strongly agree”) to 7 (“strongly disagree”). Statistical analysis All variables were entered into Microsoft Excel (Version 16.101.2; Microsoft Corporation, Redmond, WA, USA) for data management and analysis. Use of Large Language Models ChatGPT Version 5.1 (OpenAI Inc., San Francisco, USA) was used for language quality check. Results Validation Questionnaire The seven participants completed the Validation Questionnaire using a five-point Likert scale (1 = No similarity between the two environments/not useful/strongly disagree, 5 = Very satisfactory/very useful/strongly agree) (Table 1 ). Table 1 Validation Questionnaire. 1.Please rate the degree of realism of the target structures (cervix, transformation zone) (how realistic they look) in the simulator environment, compared to a real-patient environment. 2. Please rate the degree of realism of instrument handling (how realistic it feels), in the simulator environment, compared to a real-patient environment. 3. Please rate the degree of realism of instrument movement and functions (, in the simulator environment, compared to a real-patient environment. 4. Please rate the degree of realism of the tissue reaction during manipulation, compared to a real-patient environment. 5. Please rate the degree of overall realism of the simulation (how the images look and the actions feel), compared to a real-patient environment. 6. How useful is the simulator for understanding the procedural workflow? 7. How useful is the simulator for training hand-eye coordination during the LLETZ procedure? 8. How useful is the simulator for improving depth perception? 9. How useful is the simulator for training technical skills such as cutting precision? 10. The LLETZ VR simulator provides a meaningful preparation for real-life procedures. 11. Simulation training should be mandatory before performing procedures on real patients. 12. The simulator should be integrated into the gynecological residency curriculum. 13. I would use the LLETZ VR simulator for training purposes in my hospital. 14. I would recommend the simulator to colleagues. With regard to face validity (realism), the question asking about the realism of the target structures (cervix and transformation zone) in the VR simulator received a mean score of 4.3 out of 5 points. The realism of instrument handling was rated more critically, with a mean of 3.4 points. The movement and functioning of the instruments were rated with a mean of 4.0 points. The perceived realism of the tissue response showed the lowest rating within this domain, with 3.1 points. The overall question on how realistic the simulation appears and feels (visual impression and haptic feedback combined) achieved a mean score of 3.9 out of 5 points. The training and content validity of the simulator was judged more positively. The question whether the simulator helps trainees to understand the procedural workflow of LLETZ received a mean of 4.7 out of 5 points, with all seven participants giving ratings in the agreement range (4 or 5 points). Similarly, the usefulness of the simulator for training hand–eye coordination was rated with 4.6 points. The potential to improve depth perception was evaluated with a mean of 3.7 points, corresponding to moderate agreement. The item addressing the usefulness of the simulator for training technical skills such as cutting precision achieved a mean score of 4.6 out of 5 points, again with exclusively agreeing responses. The educational relevance and feasibility of implementation were also rated favorably. The statement that the LLETZ VR simulator represents a meaningful preparation for real procedures received 4.1 out of 5 points. The question whether simulation training should be mandatory before performing first procedures on patients was rated with 4.3 points. Integration of the simulator into the gynecologic training curriculum was rated with a mean of 4.3 points. Both the willingness to use the simulator in one’s own department for training purposes and the willingness to recommend it to colleagues reached mean scores of 4.3 out of 5 points, with all respondents choosing ratings in the agreement range. Overall, the questionnaire shows a consistently positive evaluation of the LLETZ VR simulator, with a mean score of 4.1 out of 5 points across all 14 items. Particularly high ratings were observed for perceived training benefit and willingness to implement the simulator in structured education. All resuls are depicted in Fig. 4 . PSSUQ-Short Additionally, the Post-Study System Usability Questionnaire Short (PSSUQ-Short) with 16 items was administered after using the VR system. The items were rated on a seven-point scale with lower scores indicating stronger agreement and thus better usability. The questionnaire covers the domains system usefulness (items 1–6), information quality (items 7–12) and interface quality (items 13–16) (Table 2 ). Table 2 Post-Study System Usability Questionnaire (PSSUQ-Short) 1. Overall, I am satisfied with how easy it is to use this system. 2. It was simple to use this system. 3. I was able to complete the tasks and scenarios quickly using this system. 4. I felt comfortable using this system. 5. It was easy to learn to use this system. 6. I believe I could become productive quickly using this system. 7. The system gave error messages that clearly told me how to fix problems. 8. Whenever I made a mistake using the system, I could recover easily and quickly. 9. The information (such as online help, on-screen messages, and other documentation) provided with this system was clear. 10. It was easy to find the information I needed. 11. The information was effective in helping me complete the tasks and scenarios. 12. The organization of information on the system screens was clear. 13. The interface of this system was pleasant. 14. I liked using the interface of this system. 15. This system has all the functions and capabilities I expect it to have. 16. Overall, I am satisfied with this system. For the system usefulness domain, participants gave a mean score of 1.7 across items 1–6. The statement addressing overall ease of use of the system received a mean of 1.7 of 7 points. The simplicity of operating the system and the ability to complete tasks quickly were both rated with 2.0 points, indicating agreement but also suggesting slightly more variability in perceived efficiency. Feeling comfortable while using the system was again evaluated with 1.7 points. Particularly positive were the items on ease of learning and becoming productive quickly, which obtained mean scores of 1.4 and 1.3 points, respectively, reflecting strong agreement that the system can be learned and used efficiently. The information quality domain (items 7–12) showed a slightly higher, but still favourable mean of 1.9 points. The clarity of error messages, i.e. whether they explained how to resolve problems, received the most critical evaluation with a mean score of 2.6 of 7 points. The item addressing how easily users could recover from mistakes scored 2.1 points, pointing to some perceived limitations in support for error recovery. In contrast, the clarity of the provided information (such as on-screen messages or help text) was rated more positively with 1.7 points. The ease of finding necessary information was rated 1.8 points, while the effectiveness of this information for completing tasks scored 1.5 points. The organization of information on the screens received a mean of 1.9 points. Regarding interface quality, the mean score across items 13–16 was 1.6 points. The visual and overall impression of the interface was judged favourably, with mean scores of 1.6 for the pleasantness of the interface and 1.4 for how much participants liked using it. The extent to which the system was perceived as having all necessary functions and capabilities was rated somewhat more cautiously with 2.1 points. Overall satisfaction with the system as a whole obtained a mean score of 1.4 of 7 points, reflecting strong agreement that users were satisfied with the VR system. Across all 16 items, the overall mean PSSUQ score was 1.8 of 7 points, corresponding to ratings between “strongly agree” and “agree.” All resuls are depicted in Fig. 5 . Discussion Principal findings from expert validation The VR LLETZ simulator was generally rated positively across all dimensions. With regard to face validity, the realism of the target structures (cervix and transformation zone) and the overall impression of the simulation were judged favourably (means 4.3 and 3.9 out of 5, respectively), whereas instrument handling and, in particular, tissue response received more moderate ratings (3.4 and 3.1). This pattern suggests that the visual and spatial representation of the procedure is already convincing for experienced colposcopists, while the absence of haptic feedback limit the perceived realism of the procedure. At the same time, content validity and perceived training value were rated very highly: participants reported that the simulator clearly supports understanding of the procedural workflow and training of hand–eye coordination and cutting precision (all means ≥ 4.6), and they expressed agreement that the system represents a meaningful preparation for real procedures and should be integrated into structured curricula. The consistently high willingness to use and recommend the simulator underscores its perceived educational relevance. Usability outcomes from the PSSUQ-Short were likewise favourable, with low mean scores across all domains (overall 1.77 on the 1–7 scale, lower values indicating better usability). Expert users found the system easy to learn and to operate, and reported feeling comfortable while using it, indicating that the technical implementation and user interface do not constitute major barriers even for VR-naïve clinicians. Taken together, these findings indicate that the current prototype already offers a usable and educationally valuable environment for practising LLETZ. Comparison with existing data and implications for gynecologic training Most existing training approaches for LLETZ rely on simple physical models, assembled from easily available materials to teach basic loop electrosurgical excision skills. These devices have demonstrated that even very low-fidelity models can improve confidence and performance metrics [ 32 – 34 ]. More recently, 3D-printed simulators have been developed to offer anatomically more realistic excision models for LLETZ, demonstrating improved user ratings for realism and training value [ 15 , 17 ]. To our knowledge, there is currently no published VR-only simulator specifically designed for LLETZ. Existing evidence for VR in gynecologic surgery is largely derived from laparoscopic simulators. Randomized trials and systematic reviews have shown that VR training can shorten procedure times, reduce intraoperative error rates, and raise novice performance to levels comparable to more experienced operators [ 35 – 37 ]. Moreover current evidence demonstrates that virtual hysteroscopy simulators effectively enhance the diagnostic and surgical skills of gynecologists, regardless of their initial level of expertise [ 38 ]. The present work demonstrates that a LLETZ-focused VR environment is both usable and judged educationally meaningful by experienced colposcopists. From an educational standpoint, the combination of high usability and favourable content validity suggests that this VR simulator may be particularly suited to the early stages of LLETZ training. It could allow residents to familiarize themselves with the procedural steps, colposcopic view, and basic loop manipulation before progressing to physical models and, ultimately, to patients. Such a stepwise approach mirrors the training pathways that have proved effective in laparoscopic surgery, where VR is used to achieve predefined proficiency levels before supervised real-world procedures [ 36 ]. Moreover, the ability to visualize the excised specimen and residual tissue interactively in three-dimensional space may facilitate deeper discussions between trainees and supervisors about optimal cone size, depth, and orientation in different clinical scenarios. If skills acquired in the simulator are at least partially transferable to clinical practice, a VR system that is rated more highly in terms of learning outcomes could, in principle, provide a more effective training experience than traditional models. At present, however, this remains a theoretical assumption rather than an established fact. Future research should therefore investigate whether integration of such VR-based training modules into residency curricula results in measurable improvements in intraoperative performance, margin status, complication rates, and long-term reproductive outcomes. Strengths and Limitations To our knowledge, this is the first VR-only simulator specifically designed for LLETZ. A key strength of the system is its open-source design, which enhances transparency, reproducibility, and the potential for external validation and further development. Developing a VR application that not only simulates loop excision in real time but also generates a separate, inspectable cone specimen presented a substantial technical challenge, and the current prototype should be regarded as an early, yet important, step in this direction. By making the tool openly available, we intend to provide a foundation on which other groups can build, refine the technology, and design further validation studies. This approach is particularly relevant in the context of increasing staff shortages, where scalable, simulator-based training has the potential to support more efficient and standardized education of residents in colposcopic surgery. The open architecture also allows institutions to tailor the platform to local curricula and to integrate the automatically generated performance metrics into digital logbooks or competency-based assessment frameworks. Another strength is that the simulator was evaluated by senior consultants with substantial experience in colposcopic surgery, so that judgements on realism and educational value were grounded in extensive clinical practice. The use of two complementary instruments—a custom, LLETZ-specific validation questionnaire and the generic PSSUQ—captured both procedure-focused and overall usability aspects. In contrast to physical simulators, the VR tool additionally provides automated performance logging, mesh-based visualization of excised versus residual tissue, and standardized digital outputs that can be reviewed asynchronously with supervisors, aligning well with current trends toward data-rich and proficiency-based simulation curricula. However, several limitations must be acknowledged, underlining the pilot character of this work. First, the sample size was very small and derived from a single tertiary centre, and all participants were senior consultants rather than residents or fellows, who represent the primary target group for such training tools. As a consequence, the generalizability of the findings is limited, and it remains unclear whether less experienced trainees would rate usability, realism and educational value in a similar way. Second, only subjective outcomes (face validity, content validity, and perceived usability) were assessed; no objective performance metrics, such as time to completion, margin adequacy, or error rates, were analysed in relation to user experience or expertise level. Third, important aspects of procedural realism remain suboptimal. Participants rated instrument handling and tissue response lower than other dimensions, which likely reflects the absence of true haptic feedback and the constraints of current consumer-grade VR controllers. Finally, although all seven participants completed the planned simulator sessions and no adverse events such as nausea, dizziness or relevant discomfort were reported, the small sample size does not allow firm conclusions regarding tolerability or acceptance in larger and more diverse learner populations. Addressing these limitations we plan future studies with larger cohorts and objective performance endpoints to determine the true educational and clinical impact of this VR LLETZ simulator. Conclusions In this preliminary validation study, we developed and evaluated a novel, open-source virtual reality simulator specifically designed for LLETZ training. The system combines realistic colposcopic visualization, real-time tissue cutting and automated performance metrics to provide an immersive and structured learning environment. Expert colposcopists rated the simulator favourably with regard to face and content validity, particularly for understanding procedural workflow, hand–eye coordination and cutting precision. Usability was likewise judged to be high, with low PSSUQ scores across all domains, indicating that the system can be learned and used efficiently even by clinicians without prior VR experience. These findings suggest that VR-based training may represent a useful complement to existing LLETZ teaching formats. At the same time, the more moderate ratings for instrument handling and tissue behaviour underline the need for further technical refinement. If these aspects can be improved and the effects on clinical performance confirmed in larger studies, this VR LLETZ simulator may contribute to safer, more standardized and ethically acceptable training pathways in the management of cervical intraepithelial neoplasia. Abbreviations LLETZ: large loop excision of the transformation zone HSIL: high-grade squamous intraepithelial lesions CIN: cervical intraepithelial neoplasia 3D: three-dimensional AR: augmented reality VR: virtual reality XR: extended reality SDF: signed distance fields CSG: constructive solid geometry UI: user interface IPD: interpupillary distance LTS: long term support Declarations Authors’ contributions All authors contributed to the study conception and design. Conceptualization: Anne Cathrine Scherer-Quenzer, Matthias Kiesel and Ute Trapp, Initial VR prototype demo and manuscript editing: Adam Kalisz, Methodology: Ute Trapp, Benjamin Meyer, Writing - original draft preparation: Anne Cathrine Scherer-Quenzer, Matthias Kiesel and Ute Trapp, Writing - review and editing: Johanna Buechel, Bettina Blau-Schneider, Quirin Notz, Supervision: Achim Woeckel. All authors read and approved the final manuscript. Funding DTR Medical (Swansea Enterprise Park, 17 Clarion Cl, Llansamlet, Swansea SA6 8RF, United Kingdom) provided the study group with two identical models of their commercial simulator LLETZlearn® Competing interests The authors have no relevant financial or non-financial interests to disclose. Ethics approval and consent to participate This study was registered with the Institutional Review Board (Ethics Committee, Faculty of Medicine, University of Wuerzburg) (Ref. No. 2025-429-ka) and approved by the ethics committee of Faculty of Medicine, University of Wuerzburg. Participation in this study was voluntary. All participants were informed about the purpose and procedures of the study and provided written informed consent before participating. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Acknowledgements none References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018; doi: 10.3322/caac.21492. Pinto AP, Crum CP. Natural history of cervical neoplasia: defining progression and its consequence. Clin Obstet Gynecol. 2000; doi: 10.1097/00003081-200006000-00015. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). 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After conisation of the cervix, the perinatal mortality as a result of preterm delivery increases in subsequent pregnancy. Bjog. 2010;117(3):258-67. Kyrgiou M, Athanasiou A, Paraskevaidi M, Mitra A, Kalliala I, Martin-Hirsch P, et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. Bmj. 2016;354:i3633. Montanari E, Grimm C, Schwameis R, Kuessel L, Polterauer S, Paternostro C, et al. Influence of training level on cervical cone size and resection margin status at conization: a retrospective study. Arch Gynecol Obstet. 2018;297(6):1517-23. Rodriguez-Paz JM, Kennedy M, Salas E, Wu AW, Sexton JB, Hunt EA, et al. Beyond "see one, do one, teach one": toward a different training paradigm. Qual Saf Health Care. 2009;18(1):63-8. Macedonia CR, Gherman RB, Satin AJ.Simulation laboratories for training in obstet-rics and gynecology. Obstet Gynecol 2003;102:388-92. Schreuder HW, van Dongen KW, Roeleveld SJ, Schijven MP, Broeders IA. Face and construct validity of virtual reality simulation of laparoscopic gynecologic surgery. Am J Obstet Gynecol. 2009 May;200(5):540.e1-8. doi: 10.1016/j.ajog.2008.12.030. Dillon S. Simulation in Obstetrics and Gynecology: A Review of the Past, Present, and Future. Obstet Gynecol Clin North Am. 2021 Dec;48(4):689-703. doi: 10.1016/j.ogc.2021.07.003. PMID: 34756290. Kiesel M, Beyers I, Kalisz A, Wöckel A, Herbert SL, Curtaz C, Diessner J, Joukhadar R, Wulff C. Introducing a novel model for simulating large loop excision of the transformation zone (LLETZ) using 3D printing technique. Arch Gynecol Obstet. 2022 Mar;305(3):703-712. doi: 10.1007/s00404-021-06209-1. Edmonds K, Warner S, Endicott S. Advances in gynecologic simulation: implementation, validity, and new resources. Curr Opin Obstet Gynecol. 2024 Aug 1;36(4):296-300. doi: 10.1097/GCO.0000000000000963. Epub 2024 May 20. PMID: 38837238. Kiesel M, Beyers I, Kalisz A, Wöckel A, Löb S, Schlaiss T, Wulff C, Diessner J. Evaluating a novel 3D printed model for simulating Large Loop Excision of the Transformation Zone (LLETZ). 3D Print Med. 2022 Jun 8;8(1):15. doi: 10.1186/s41205-022-00143-x. Costello DM, Huntington I, Burke G, Farrugia B, O'Connor AJ, Costello AJ, Thomas BC, Dundee P, Ghazi A, Corcoran N. A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education. J Robot Surg. 2022 Aug;16(4):749-763. doi: 10.1007/s11701-021-01302-8. Ismail FW, Ajani K, Baqir SM, Nadeem A, Qureshi R, Petrucka P. Challenges and opportunities in the uptake of simulation in healthcare education in the developing world: a scoping review. MedEdPublish (2016). 2024 May 24;14:38. doi: 10.12688/mep.20271.1. K. Cheng, “Reflection on the application of vr technology in the teaching of gynecological surgery for regular trainees,” Journal of Higher Education Research, vol. 4, p. 48, 04 2023. S. S. Lie, N. Helle, N. V. Sletteland, M. D. Vikman, and T. Bonsaksen, “Implementation of virtual reality in health professions education: Scoping review,” JMIR Med Educ, vol. 9, p. e41589, Jan 2023. [Online]. Available: https://mededu.jmir.org/2023/1/e41589 Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg. 2007 Nov;246(5):771-9. doi: 10.1097/SLA.0b013e3180f61b09. Sun P, Zhao Y, Men J, Ma ZR, Jiang HZ, Liu CY, Feng W. Application of Virtual and Augmented Reality Technology in Hip Surgery: Systematic Review. J Med Internet Res. 2023 Mar 10;25:e37599. doi: 10.2196/37599. University of Applied Sciences Darmstadt. VR-Koni-Trainer . V. 1.0.9. Released 2026. https://gitlab.com/darmstadt-university-of-applied-sciences-trapp/vr-koni-trainer. Technologies, Unity. “Unity - Manual: OpenXR Plugin.” Accessed January 19, 2026. https://docs.unity3d.com/6000.3/Documentation/Manual/com.unity.xr.openxr.html. Sansone, Lucia Grazia, Ronny Stanzani, Mirko Job, Simone Battista, Alessio Signori, and Marco Testa. “Robustness and Static-Positional Accuracy of the SteamVR 1.0 Virtual Reality Tracking System.” Virtual Reality 26, no. 3 (2022): 903–24. https://doi.org/10.1007/s10055-021-00584-5. Sloan, S. W. “A Fast Algorithm for Constructing Delaunay Triangulations in the Plane.” Advances in Engineering Software (1978) 9, no. 1 (1987): 34–55. https://doi.org/10.1016/0141-1195(87)90043-X. Wilpert, Dennis. “Mesh Creation and Manipulation of Existing Mesh Objects in a Virtual Reality Environment.” Master’s thesis, University of Applied Sciences Darmstadt, 2024. Reschke, Fabian. “Verwendung von Constructive Solid Geometry Zum Ausschaben von Volumen Aus Oberflächenmeshes.” Bachelorarbeit, University of Applied Sciences Darmstadt, 2025. https://gitlab.com/darmstadt-university-of-applied-sciences-trapp/vr-koni-trainer/-/blob/main/publications/Verwendung-von-Constructive-Solid-Geometry-zum-Ausschaben-von-Volumen-aus-Oberflaechenmeshes.pdf?ref_type=heads. Takacs FZ, Radosa JC, Gerlinger C, Findeklee S, Juhasz-Böss I, Solomayer EF, Hamza A. Introduction of a learning model for type 1 loop excision of the transformation zone of the uterine cervix in undergraduate medical students: a prospective cohort study. Arch Gynecol Obstet. 2019 Mar;299(3):817-824. doi: 10.1007/s00404-018-5019-7. https://docs.unity3d.com/6000.3/Documentation/Manual/ui-systems/introduction-ui-toolkit.html Vella PV. A simple trainer for the loop electrosurgical excision procedure. Aust N Z J Obstet Gynaecol. 2002 Aug;42(3):289-91. doi: 10.1111/j.0004-8666.2002.00289.x. Wilson EB, Beckmann MM, Hewett DG, Jolly BC, Janssens S. Evaluation of a Low-Fidelity Surgical Simulator for Large Loop Excision of the Transformation Zone (LLETZ). Simul Healthc. 2017 Oct;12(5):304-307. doi: 10.1097/SIH.0000000000000242. Rezniczek GA, Severin S, Hilal Z, Dogan A, Krentel H, Buerkle B, Tempfer CB. Surgical performance of large loop excision of the transformation zone in a training model: A prospective cohort study. Medicine (Baltimore). 2017 Jun;96(23):e7026. doi: 10.1097/MD.0000000000007026. Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK, Andersen DK, Satava RM. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002 Oct;236(4):458-63; discussion 463-4. doi: 10.1097/00000658-200210000-00008. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, Schroeder TV, Ottesen BS. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ. 2009 May 14;338:b1802. doi: 10.1136/bmj.b1802. Erratum in: BMJ. 2009;338. doi: 10.1136/bmj.b2074. Larsen CR, Oestergaard J, Ottesen BS, Soerensen JL. The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1015-28. doi: 10.1111/j.1600-0412.2012.01482.x. Vitale SG, Caruso S, Vitagliano A, Vilos G, Di Gregorio LM, Zizolfi B, Tesarik J, Cianci A. The value of virtual reality simulators in hysteroscopy and training capacity: a systematic review. Minim Invasive Ther Allied Technol. 2020 Aug;29(4):185-193. doi: 10.1080/13645706.2019.1625404. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 18 Feb, 2026 Editor invited by journal 18 Feb, 2026 Editor assigned by journal 17 Feb, 2026 Submission checks completed at journal 17 Feb, 2026 First submitted to journal 14 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8882607","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594902176,"identity":"0ad3587e-9d07-4e2a-9c62-bf35c0f810cc","order_by":0,"name":"Anne Cathrine Scherer-Quenzer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYFAD9gZmIMlMihaeAyRrkUggUgvfjeRjD39U3GPgn/nG2JiHwVqOoBbJG2npBhJnihkkbucYJ/MwpBsT1GJwI8dMwrAtgYEBqOVwDsPhxAbCWvK/SST+S2CQv3kGrKWeCC05bBIHGxKADB7jZKCWBMJ+OfPMTLLhWAKD4Zm0YuM/BumGBG3hO578TPJHTQKD3PHDmyVnVFjLE7SF4QCEgnrBgLAGuJZRMApGwSgYBbgBAPHvOL6CX/crAAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":true,"prefix":"","firstName":"Anne","middleName":"Cathrine","lastName":"Scherer-Quenzer","suffix":""},{"id":594902179,"identity":"31f4edde-f2d8-4b65-8736-fa367bdaa483","order_by":1,"name":"Ute Trapp","email":"","orcid":"","institution":"University of Applied Sciences Darmstadt","correspondingAuthor":false,"prefix":"","firstName":"Ute","middleName":"","lastName":"Trapp","suffix":""},{"id":594902181,"identity":"47051f44-a4f3-464d-af18-22d61f9319db","order_by":2,"name":"Benjamin Meyer","email":"","orcid":"","institution":"University of Applied Sciences Darmstadt","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Meyer","suffix":""},{"id":594902183,"identity":"e732a0eb-10b7-4924-97ac-1c5bed3dbaba","order_by":3,"name":"Quirin Notz","email":"","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":false,"prefix":"","firstName":"Quirin","middleName":"","lastName":"Notz","suffix":""},{"id":594902186,"identity":"bd0d82db-ef2c-42db-8cbd-16ea1bbe06df","order_by":4,"name":"Adam Kalisz","email":"","orcid":"","institution":"Fraunhofer Institute for Integrated Circuits IIS","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Kalisz","suffix":""},{"id":594902189,"identity":"d8b7e5a1-5c59-4674-abd4-44970d0ec684","order_by":5,"name":"Bettina Blau-Schneider","email":"","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":false,"prefix":"","firstName":"Bettina","middleName":"","lastName":"Blau-Schneider","suffix":""},{"id":594902192,"identity":"a07a5bc1-9887-41f6-9036-59ed7d0d20b8","order_by":6,"name":"Johanna Buechel","email":"","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Buechel","suffix":""},{"id":594902196,"identity":"6a957db5-bdb7-4c90-aeb2-e67df99cfb88","order_by":7,"name":"Achim Wöckel","email":"","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":false,"prefix":"","firstName":"Achim","middleName":"","lastName":"Wöckel","suffix":""},{"id":594902198,"identity":"959e2341-c1bc-4aa8-8b67-3aabd7b8fc0b","order_by":8,"name":"Matthias Kiesel","email":"","orcid":"","institution":"University Hospital Wuerzburg","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Kiesel","suffix":""}],"badges":[],"createdAt":"2026-02-14 21:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8882607/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8882607/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103362817,"identity":"aa4cf43b-937a-447d-be67-e49f467a3fd4","added_by":"auto","created_at":"2026-02-24 21:34:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":610481,"visible":true,"origin":"","legend":"\u003cp\u003eScreenshot of the\u003cstrong\u003e \u003c/strong\u003esurgical environment. The figure shows a gynecological examination chair with a colposcope positioned in front. The cervix is depicted as a cone (patient representation was intentionally omitted). Surgical instruments can be placed on the instrument table (right side of the image).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/56ced5c5afe990a1f486f8a8.png"},{"id":103506976,"identity":"491429ea-d602-4a55-b40c-517afe1eec6e","added_by":"auto","created_at":"2026-02-26 13:40:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":474868,"visible":true,"origin":"","legend":"\u003cp\u003eScreenshot of the participant’s colposcopic view during LLETZ procedure. The speculum is visualized on the left side oft the cervix. The surgical instrument is visualized on the right. The cervix is represented as a cylinder.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/1a789a130c38c4f2153a8aed.png"},{"id":103362818,"identity":"0ee0026e-516f-4914-9e27-d4c6b150234e","added_by":"auto","created_at":"2026-02-24 21:34:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":200885,"visible":true,"origin":"","legend":"\u003cp\u003eScreenshot of the participant’s interface displaying the surgical performance results. The LLETZ/LEEP adequacy score is calculated according to the methodology described by Takacs et al. [30]. The lower panel shows screenshots of the excised specimen.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/9fac540f860dd46e3989bf02.png"},{"id":103362822,"identity":"bf4db048-3d04-443a-812f-fe1fe796acd4","added_by":"auto","created_at":"2026-02-24 21:34:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":75902,"visible":true,"origin":"","legend":"\u003cp\u003eMean validation scores of seven participants on the validation questionnaire after completing five conizations. The boxes indicate the interquartile range. The blue bar within the boxes shows the median, the triangle represent the mean value.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/620253a34c1492a98bea7f1d.png"},{"id":103507041,"identity":"96216239-d1f3-46e9-9e05-bffcd16721eb","added_by":"auto","created_at":"2026-02-26 13:40:16","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":135067,"visible":true,"origin":"","legend":"\u003cp\u003eMean validation scores of seven participants on the PSSUQ questionnaire after completing five conizations. The boxes indicate the interquartile range. The blue bar within the boxes shows the median, the triangle represents the mean value.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/6a00a205f7fe72b968f9a7d7.png"},{"id":103510022,"identity":"d3476aa6-93f5-466c-b254-8408674a7039","added_by":"auto","created_at":"2026-02-26 14:02:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2253157,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8882607/v1/5c34d2ca-d2fb-4ed4-9329-3d270d1754e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A novel virtual reality-based simulator for training in LLETZ procedures: Development and preliminary validation","fulltext":[{"header":"Background","content":"\u003cp\u003eCervical cancer is the fourth most common cancer in women worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The majority of cases originate from precancerous changes in cervical epithelial cells, known as cervical intraepithelial neoplasia (CIN) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When a high-grade squamous intraepithelial lesion (HSIL) is detected, surgical excision is generally recommended to prevent progression to invasive carcinoma. Among the available excision and ablation techniques, large loop excision of the transformation zone (LLETZ) represents the standard of care for treating HSIL and other high-grade dysplastic lesions [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In Germany alone, more than 100,000 LLETZ procedures are performed annually [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although LLETZ is a routine and well-established procedure, it remains technically challenging and carries notable risks such as incomplete excision, bleeding, or cervical insufficiency in subsequent pregnancies [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Traditional surgical education follows the principle of \u0026ldquo;learning by doing,\u0026rdquo; where residents acquire procedural skills directly on patients under supervision. Given these risks, such a training model raises important ethical and patient safety concerns [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, there is a growing consensus that modern gynecologic training should incorporate simulation-based learning to improve surgical competence in a controlled and risk-free environment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Simulation-based education enables repetitive practice without patient risk, facilitates objective performance assessment, and allows exposure to rare or critical situations that may not occur frequently in clinical settings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In gynecology, various forms of simulation have been introduced, ranging from simple low-fidelity models to advanced computer-based systems [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Traditional physical simulators for LLETZ\u0026mdash;often self-constructed or commercially available cervical models\u0026mdash;have been used to train visualization and excision techniques [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these models typically require continuous instructor supervision, are time-consuming to set up, and can be costly to maintain. Moreover, they lack standardized feedback mechanisms and are difficult to scale for larger educational programs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent advances in digital technology have made virtual reality (VR) an attractive alternative for medical training. VR-based simulators provide immersive, interactive environments that allow trainees to perform procedures repeatedly and receive automated feedback without direct supervision [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. VR has already been shown to shorten learning curves and enhance skill acquisition in various surgical disciplines, including laparoscopy and orthopedics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], However, to date, no dedicated VR simulator for the LLETZ procedure has been reported. Moreover, no open-source solution currently exists that enables reproducible training scenarios, anonymized data export, and asynchronous expert evaluation for LLETZ training.\u003c/p\u003e \u003cp\u003eTo address this gap, we developed a novel virtual reality-based simulator specifically designed for training in LLETZ procedures. The system integrates realistic colposcopic visualization, real-time tissue cutting, and automated performance analysis. Senior consultants were invited to test the simulator to evaluate its face and content validity and its overall usefulness. This work represents an important step toward establishing an accessible, standardized, and objective VR training platform for cervical excision procedures in gynecology.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe following section intentionally provides a detailed technical description. It explains the design process of the VR simulator, the tools which have been used to implement it, technical challenges which have been faced, how they have been addressed during the development and how the gathered training data is recorded to generate detailed performance reports for each participant. These contribute to both, system fidelity and measurement precision, which are central to evaluating the validity of VR-based surgical training tools.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Development Process of the VR-simulator\u003c/h2\u003e \u003cp\u003eThe simulator was developed using an iterative, user-centered design process, with repeated formative evaluations conducted together with senior gynecological consultants and physicians in training. Representative descriptions of typical end users, user personas, were formulated to consider the goals, desires and technical experience of the expected training participant. With the personas in mind, a short tutorial and usability tests have been created. During the usability test sessions, feedback from these expert users informed successive refinements of interaction design, onboarding, ergonomics, and performance assessment throughout development.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSoftware and platform information\u003c/h3\u003e\n\u003cp\u003eThe VR application itself was created in the Unity Engine (version 6.3) and incorporates several 3D assets that were modeled and textured in Blender (version 4.5.4 LTS) before being imported into Unity. Unity is a software which is used to develop immersive games and interactive simulations. The application source code is hosted in a public GitLab repository [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and released under an MIT-style open-source license. The application runs on Windows 11, Android and any OpenXR [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] capable VR-Headset.\u003c/p\u003e\n\u003ch3\u003eDesign of digital assets\u003c/h3\u003e\n\u003cp\u003eAs an initial step, Blender software (version 4.5.4 LTS) was utilized, to construct a simplified three-dimensional model representing a colposcope and the surgical environment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All instruments (colposcope, speculum, electrosurgical loop, smoke extractor) were created with clinically accurate dimensions based on specifications of equipment currently deployed at University Hospital W\u0026uuml;rzburg. The colposcope model replicates optical geometry and working distance of clinical devices. The electrosurgical loop was modeled to match commonly used LLETZ loop sizes (typically 15\u0026ndash;20 mm width and 10\u0026ndash;15 mm depth). Given the open-source nature and potential for uncontrolled distribution, anatomical representations were deliberately abstracted: the cervix is represented as a cylinder and the portio as a torus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eRealistic colposcopic simulation and visualization\u003c/h3\u003e\n\u003cp\u003eTo replicate optical characteristics relevant for stereoscopic depth perception, working distance (~\u0026thinsp;20 cm from virtual headset camera to cervix, derived from clinical practice) and interpupillary distance (IPD) were derived from technical specifications of a clinical colposcope in use at University Hospital W\u0026uuml;rzburg. Because Unity does not provide a general, direct low-level control of the stereo view matrix from the VR camera rig for IPD changes in all OpenXR configurations, IPD adjustment was implemented by calculating a scaling factor: colposcope-derived IPD divided by the headset-native camera IPD (configured by Unity/OpenXR per device). The camera rig was then scaled horizontally along the x-axis by this factor, enabling stereoscopic alignment without directly modifying the view matrix. In addition, three discrete zoom levels (1\u0026times;, 2\u0026times;, 3\u0026times;) replicate common colposcope magnification steps.\u003c/p\u003e\n\u003ch3\u003eInteraction design and tracking accuracy considerations\u003c/h3\u003e\n\u003cp\u003eInstrument interaction is controller-based and designed to support repeated practice without instructor supervision. Collision handling (i.e. between instrument and tissue) and bound checks were implemented to prevent physically implausible tool positions from silently corrupting spatial learning by providing extensive feedback to the user (see \u0026ldquo;Ergonomic and safety design\u0026rdquo; below). The tracking accuracy of the employed head-mounted display is sufficient for the spatial requirements of LLETZ simulation. The Valve Index provides positional accuracy in the millimeter range [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which is adequate given an excision depth of approximately 8\u0026ndash;10 mm and an excision width of about 2 cm. This level of accuracy was confirmed by our own measurements. Additional measurements conducted with a Meta Quest 3 showed slightly lower, yet still sufficient, positional accuracy, remaining within the millimeter range required for the task.\u003c/p\u003e \u003cp\u003eReal-time tissue cutting engine\u003c/p\u003e \u003cp\u003eThe cutting algorithm was designed to enable stable real-time excision across complex cervical geometry, including the clinically relevant convex\u0026ndash;concave\u0026ndash;convex transition at the external cervical os, while allowing continuous depth measurements and the generation of both the excised specimen and the residual cervix. Real-time cutting proved to be the most technically demanding component of the simulator; therefore, three algorithmic approaches were iteratively explored. An initial prototype based on constrained Delaunay triangulation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] was limited by the computational complexity of reassembling mesh topology after cutting and showed instability when crossing the cervical os transition, resulting in mesh artifacts and topological errors [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A subsequent constructive solid geometry (CSG) approach improved geometric stability but raised concerns regarding long-term library maintenance, borderline performance for complex excision shapes, and limited maintainability of the implementation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The current solution employs signed distance fields (SDF) with ray marching, which provides robust handling of arbitrary cutting paths, maintains real-time performance, and supports quantitative measurements (e.g., depth and volume) required for automated feedback. In this implementation, both the surgical instrument and the approximated cervical tissue model are represented using an SDF ray-marching approach. Conceptually, the SDF represents tissue as a mathematical function rather than a surface mesh, which avoids topological instability during cutting and enables robust Boolean operations. During the procedure, the loop pose is recorded continuously; the resulting cutting volume is then applied as a Boolean subtraction on the SDF to generate (1) the excised tissue specimen and (2) the residual cervical representation. This approach further enables computation of quantitative metrics such as resection depth progression and excised volume.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData logging, analytics, and automated scoring\u003c/h2\u003e \u003cp\u003eThe simulator continuously captures clinically relevant parameters, including cutting depth progression sampled at 60 Hz during active cutting, tissue contact patterns (duration/frequency of loop contact with the portio versus the cylindrical cervix representation treated as a critical error region), and loop velocity to identify rushed or hesitant technique. To support margin assessment and cone-shape verification, multi-angle screenshots of the excised tissue are captured automatically from standardized viewpoints. Additionally, post-procedure 3D visualization of residual versus excised tissue is provided for debriefing and structured feedback discussions. In addition, an automated LLETZ/LEEP adequacy score is computed following the methodology described by Takacs et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These standardized outputs are intended to complement, not replace, expert instructor judgment (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePersistence, export, and user interface (UI) design\u003c/h3\u003e\n\u003cp\u003eA hybrid persistence strategy balances performance and accessibility: session metadata, metrics, and scoring are stored in a SQLite database (and can be exported as an Excel file for further analysis); and screenshots as PNG files. SQLite was chosen as it is a fast, small, widely-deployed and cross-platform database engine which does not rely on a separate server process but directly reads and writes to disk. This design enables longitudinal skill tracking across sessions and supports reconstruction of procedures for detailed review. Preparation and detailed post-operative data review are presented primarily on desktop displays to reduce discomfort during prolonged analysis of graphs and numerical information. Procedural cues required during the excision remain available within VR using world-space UI elements. Unity\u0026rsquo;s UI Toolkit world-space workflows were leveraged for the standalone-compatible interface components (Unity documentation) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSystem enhancements\u003c/h3\u003e\n\u003cp\u003eA speculum was added to improve anatomical context, and smoke generation with extraction visualization was implemented to enhance realism during electrosurgical cutting. To maximize accessibility in clinical environments, the system supports standalone operation on compatible headsets (e.g., Meta Quest). Users begin in a virtual waiting room displaying preparatory information (procedure overview, learning objectives, controller instructions). This additional scene was introduced in response to early expert feedback, as initial versions that placed users directly in the operating room led to spatial disorientation and reduced task readiness. After completion, performance data can be uploaded to a Nextcloud instance to enable asynchronous expert evaluation.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eErgonomic and safety design\u003c/h2\u003e \u003cp\u003eTo compensate for missing true haptic feedback, the simulator provides layered feedback: (1) differentiated controller vibration patterns (gentle vibration for correct portio contact; strong distinct pattern for critical error zones), (2) audio cues during energized cutting, and zoom change of the colposcope and (3) visual warnings including critical error notifications. For severe safety violations (e.g., activated loop contacting critical tissue regions or excessive depth beyond a predefined threshold), the simulation terminates immediately to reinforce safety learning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEquipment\u003c/h2\u003e \u003cp\u003eOur system consists of a VR setup built around the Valve Index\u0026reg; headset (Valve Corporation, Bellevue, USA), which provides tracking for both the headset and the controllers. The workstation driving the simulation is a custom-built PC (Gigabyte B650 Eagle AX motherboard) equipped with an AMD Ryzen 5 7600X processor, ASUS Dual GeForce RTX 5060 Ti 16 GB OC graphics card, and 32 GB DDR5 RAM.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eSeven consultant gynecologists from the Department of Obstetrics and Gynecology at the University Hospital W\u0026uuml;rzburg voluntarily participated in the study. Each of them had at least 5 years of expert experience in the field of colposcopic surgery. None of the participants had prior contact to the virtual reality simulator and none of them had been involved in the process of development. Each participant received a brief introduction to the VR hardware and controls and performed five standardized LLETZ procedures on a virtual cervix with a predefined high-grade lesion. Participants were asked to complete the excision as they would in clinical practice. After finishing the procedure and reviewing the automated performance metrics, they removed the headset and immediately completed the validation questionnaire followed by the PSSUQ.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaires\u003c/h2\u003e \u003cp\u003eThe validation questionnaire comprised 14 closed-ended items and two open-ended questions evaluating the virtual reality (VR) simulator for Large Loop Excision of the Transformation Zone (LLETZ). The first five statements assessed the face validity of the simulator, focusing on the realism of anatomical structures, instrument handling, and tissue response. The next four statements addressed the content validity, evaluating the simulator\u0026rsquo;s usefulness for understanding procedural workflow and training relevant technical and perceptual skills. Subsequently, five statements explored the educational value and applicability of the simulator in clinical training. All items were rated on a five-point Likert scale ranging from 1 (\u0026ldquo;not realistic/useful\u0026rdquo;) to 5 (\u0026ldquo;very realistic/useful\u0026rdquo;). Finally, participants were invited to provide open-ended comments on the most realistic or helpful aspects of the simulation and to suggest improvements for future versions.\u003c/p\u003e \u003cp\u003eThe Post-Study System Usability Questionnaire Short (PSSUQ-Short) with 16 items was administered to evaluate system usability. The questionnaire covers the domains system usefulness (items 1\u0026ndash;6), information quality (items 7\u0026ndash;12) and interface quality (items 13\u0026ndash;16). All items were rated on a scale ranging from 1 (\u0026ldquo;strongly agree\u0026rdquo;) to 7 (\u0026ldquo;strongly disagree\u0026rdquo;).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll variables were entered into Microsoft Excel (Version 16.101.2; Microsoft Corporation, Redmond, WA, USA) for data management and analysis.\u003c/p\u003e \u003cp\u003eUse of Large Language Models\u003c/p\u003e \u003cp\u003eChatGPT Version 5.1 (OpenAI Inc., San Francisco, USA) was used for language quality check.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eValidation Questionnaire\u003c/p\u003e \u003cp\u003eThe seven participants completed the Validation Questionnaire using a five-point Likert scale (1\u0026thinsp;=\u0026thinsp;No similarity between the two environments/not useful/strongly disagree, 5\u0026thinsp;=\u0026thinsp;Very satisfactory/very useful/strongly agree) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eValidation Questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Please rate the degree of realism of the target structures (cervix, transformation zone) (how realistic they look) in the simulator environment, compared to a real-patient environment.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Please rate the degree of realism of instrument handling (how realistic it feels), in the simulator environment, compared to a real-patient environment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Please rate the degree of realism of instrument movement and functions (, in the simulator environment, compared to a real-patient environment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Please rate the degree of realism of the tissue reaction during manipulation, compared to a real-patient environment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Please rate the degree of overall realism of the simulation (how the images look and the actions feel), compared to a real-patient environment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. How useful is the simulator for understanding the procedural workflow?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. How useful is the simulator for training hand-eye coordination during the LLETZ procedure?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. How useful is the simulator for improving depth perception?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. How useful is the simulator for training technical skills such as cutting precision?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. The LLETZ VR simulator provides a meaningful preparation for real-life procedures.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Simulation training should be mandatory before performing procedures on real patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. The simulator should be integrated into the gynecological residency curriculum.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. I would use the LLETZ VR simulator for training purposes in my hospital.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. I would recommend the simulator to colleagues.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith regard to face validity (realism), the question asking about the realism of the target structures (cervix and transformation zone) in the VR simulator received a mean score of 4.3 out of 5 points. The realism of instrument handling was rated more critically, with a mean of 3.4 points. The movement and functioning of the instruments were rated with a mean of 4.0 points. The perceived realism of the tissue response showed the lowest rating within this domain, with 3.1 points. The overall question on how realistic the simulation appears and feels (visual impression and haptic feedback combined) achieved a mean score of 3.9 out of 5 points.\u003c/p\u003e \u003cp\u003eThe training and content validity of the simulator was judged more positively. The question whether the simulator helps trainees to understand the procedural workflow of LLETZ received a mean of 4.7 out of 5 points, with all seven participants giving ratings in the agreement range (4 or 5 points). Similarly, the usefulness of the simulator for training hand\u0026ndash;eye coordination was rated with 4.6 points. The potential to improve depth perception was evaluated with a mean of 3.7 points, corresponding to moderate agreement. The item addressing the usefulness of the simulator for training technical skills such as cutting precision achieved a mean score of 4.6 out of 5 points, again with exclusively agreeing responses.\u003c/p\u003e \u003cp\u003eThe educational relevance and feasibility of implementation were also rated favorably. The statement that the LLETZ VR simulator represents a meaningful preparation for real procedures received 4.1 out of 5 points. The question whether simulation training should be mandatory before performing first procedures on patients was rated with 4.3 points. Integration of the simulator into the gynecologic training curriculum was rated with a mean of 4.3 points. Both the willingness to use the simulator in one\u0026rsquo;s own department for training purposes and the willingness to recommend it to colleagues reached mean scores of 4.3 out of 5 points, with all respondents choosing ratings in the agreement range.\u003c/p\u003e \u003cp\u003eOverall, the questionnaire shows a consistently positive evaluation of the LLETZ VR simulator, with a mean score of 4.1 out of 5 points across all 14 items. Particularly high ratings were observed for perceived training benefit and willingness to implement the simulator in structured education. All resuls are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePSSUQ-Short\u003c/p\u003e \u003cp\u003eAdditionally, the Post-Study System Usability Questionnaire Short (PSSUQ-Short) with 16 items was administered after using the VR system. The items were rated on a seven-point scale with lower scores indicating stronger agreement and thus better usability. The questionnaire covers the domains system usefulness (items 1\u0026ndash;6), information quality (items 7\u0026ndash;12) and interface quality (items 13\u0026ndash;16) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-Study System Usability Questionnaire (PSSUQ-Short)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Overall, I am satisfied with how easy it is to use this system.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. It was simple to use this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. I was able to complete the tasks and scenarios quickly using this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. I felt comfortable using this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. It was easy to learn to use this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. I believe I could become productive quickly using this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. The system gave error messages that clearly told me how to fix problems.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Whenever I made a mistake using the system, I could recover easily and quickly.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. The information (such as online help, on-screen messages, and other documentation) provided with this system was clear.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. It was easy to find the information I needed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. The information was effective in helping me complete the tasks and scenarios.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. The organization of information on the system screens was clear.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. The interface of this system was pleasant.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. I liked using the interface of this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. This system has all the functions and capabilities I expect it to have.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Overall, I am satisfied with this system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor the system usefulness domain, participants gave a mean score of 1.7 across items 1\u0026ndash;6. The statement addressing overall ease of use of the system received a mean of 1.7 of 7 points. The simplicity of operating the system and the ability to complete tasks quickly were both rated with 2.0 points, indicating agreement but also suggesting slightly more variability in perceived efficiency. Feeling comfortable while using the system was again evaluated with 1.7 points. Particularly positive were the items on ease of learning and becoming productive quickly, which obtained mean scores of 1.4 and 1.3 points, respectively, reflecting strong agreement that the system can be learned and used efficiently.\u003c/p\u003e \u003cp\u003eThe information quality domain (items 7\u0026ndash;12) showed a slightly higher, but still favourable mean of 1.9 points. The clarity of error messages, i.e. whether they explained how to resolve problems, received the most critical evaluation with a mean score of 2.6 of 7 points. The item addressing how easily users could recover from mistakes scored 2.1 points, pointing to some perceived limitations in support for error recovery. In contrast, the clarity of the provided information (such as on-screen messages or help text) was rated more positively with 1.7 points. The ease of finding necessary information was rated 1.8 points, while the effectiveness of this information for completing tasks scored 1.5 points. The organization of information on the screens received a mean of 1.9 points.\u003c/p\u003e \u003cp\u003eRegarding interface quality, the mean score across items 13\u0026ndash;16 was 1.6 points. The visual and overall impression of the interface was judged favourably, with mean scores of 1.6 for the pleasantness of the interface and 1.4 for how much participants liked using it. The extent to which the system was perceived as having all necessary functions and capabilities was rated somewhat more cautiously with 2.1 points. Overall satisfaction with the system as a whole obtained a mean score of 1.4 of 7 points, reflecting strong agreement that users were satisfied with the VR system.\u003c/p\u003e \u003cp\u003eAcross all 16 items, the overall mean PSSUQ score was 1.8 of 7 points, corresponding to ratings between \u0026ldquo;strongly agree\u0026rdquo; and \u0026ldquo;agree.\u0026rdquo; All resuls are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrincipal findings from expert validation\u003c/p\u003e \u003cp\u003eThe VR LLETZ simulator was generally rated positively across all dimensions. With regard to face validity, the realism of the target structures (cervix and transformation zone) and the overall impression of the simulation were judged favourably (means 4.3 and 3.9 out of 5, respectively), whereas instrument handling and, in particular, tissue response received more moderate ratings (3.4 and 3.1). This pattern suggests that the visual and spatial representation of the procedure is already convincing for experienced colposcopists, while the absence of haptic feedback limit the perceived realism of the procedure. At the same time, content validity and perceived training value were rated very highly: participants reported that the simulator clearly supports understanding of the procedural workflow and training of hand\u0026ndash;eye coordination and cutting precision (all means\u0026thinsp;\u0026ge;\u0026thinsp;4.6), and they expressed agreement that the system represents a meaningful preparation for real procedures and should be integrated into structured curricula. The consistently high willingness to use and recommend the simulator underscores its perceived educational relevance. Usability outcomes from the PSSUQ-Short were likewise favourable, with low mean scores across all domains (overall 1.77 on the 1\u0026ndash;7 scale, lower values indicating better usability). Expert users found the system easy to learn and to operate, and reported feeling comfortable while using it, indicating that the technical implementation and user interface do not constitute major barriers even for VR-na\u0026iuml;ve clinicians. Taken together, these findings indicate that the current prototype already offers a usable and educationally valuable environment for practising LLETZ.\u003c/p\u003e \u003cp\u003eComparison with existing data and implications for gynecologic training\u003c/p\u003e \u003cp\u003eMost existing training approaches for LLETZ rely on simple physical models, assembled from easily available materials to teach basic loop electrosurgical excision skills. These devices have demonstrated that even very low-fidelity models can improve confidence and performance metrics [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. More recently, 3D-printed simulators have been developed to offer anatomically more realistic excision models for LLETZ, demonstrating improved user ratings for realism and training value [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To our knowledge, there is currently no published VR-only simulator specifically designed for LLETZ. Existing evidence for VR in gynecologic surgery is largely derived from laparoscopic simulators. Randomized trials and systematic reviews have shown that VR training can shorten procedure times, reduce intraoperative error rates, and raise novice performance to levels comparable to more experienced operators [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Moreover current evidence demonstrates that virtual hysteroscopy simulators effectively enhance the diagnostic and surgical skills of gynecologists, regardless of their initial level of expertise [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present work demonstrates that a LLETZ-focused VR environment is both usable and judged educationally meaningful by experienced colposcopists. From an educational standpoint, the combination of high usability and favourable content validity suggests that this VR simulator may be particularly suited to the early stages of LLETZ training. It could allow residents to familiarize themselves with the procedural steps, colposcopic view, and basic loop manipulation before progressing to physical models and, ultimately, to patients. Such a stepwise approach mirrors the training pathways that have proved effective in laparoscopic surgery, where VR is used to achieve predefined proficiency levels before supervised real-world procedures [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Moreover, the ability to visualize the excised specimen and residual tissue interactively in three-dimensional space may facilitate deeper discussions between trainees and supervisors about optimal cone size, depth, and orientation in different clinical scenarios.\u003c/p\u003e \u003cp\u003eIf skills acquired in the simulator are at least partially transferable to clinical practice, a VR system that is rated more highly in terms of learning outcomes could, in principle, provide a more effective training experience than traditional models. At present, however, this remains a theoretical assumption rather than an established fact. Future research should therefore investigate whether integration of such VR-based training modules into residency curricula results in measurable improvements in intraoperative performance, margin status, complication rates, and long-term reproductive outcomes.\u003c/p\u003e \u003cp\u003eStrengths and Limitations\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first VR-only simulator specifically designed for LLETZ. A key strength of the system is its open-source design, which enhances transparency, reproducibility, and the potential for external validation and further development. Developing a VR application that not only simulates loop excision in real time but also generates a separate, inspectable cone specimen presented a substantial technical challenge, and the current prototype should be regarded as an early, yet important, step in this direction. By making the tool openly available, we intend to provide a foundation on which other groups can build, refine the technology, and design further validation studies. This approach is particularly relevant in the context of increasing staff shortages, where scalable, simulator-based training has the potential to support more efficient and standardized education of residents in colposcopic surgery. The open architecture also allows institutions to tailor the platform to local curricula and to integrate the automatically generated performance metrics into digital logbooks or competency-based assessment frameworks. Another strength is that the simulator was evaluated by senior consultants with substantial experience in colposcopic surgery, so that judgements on realism and educational value were grounded in extensive clinical practice. The use of two complementary instruments\u0026mdash;a custom, LLETZ-specific validation questionnaire and the generic PSSUQ\u0026mdash;captured both procedure-focused and overall usability aspects. In contrast to physical simulators, the VR tool additionally provides automated performance logging, mesh-based visualization of excised versus residual tissue, and standardized digital outputs that can be reviewed asynchronously with supervisors, aligning well with current trends toward data-rich and proficiency-based simulation curricula.\u003c/p\u003e \u003cp\u003eHowever, several limitations must be acknowledged, underlining the pilot character of this work. First, the sample size was very small and derived from a single tertiary centre, and all participants were senior consultants rather than residents or fellows, who represent the primary target group for such training tools. As a consequence, the generalizability of the findings is limited, and it remains unclear whether less experienced trainees would rate usability, realism and educational value in a similar way. Second, only subjective outcomes (face validity, content validity, and perceived usability) were assessed; no objective performance metrics, such as time to completion, margin adequacy, or error rates, were analysed in relation to user experience or expertise level. Third, important aspects of procedural realism remain suboptimal. Participants rated instrument handling and tissue response lower than other dimensions, which likely reflects the absence of true haptic feedback and the constraints of current consumer-grade VR controllers. Finally, although all seven participants completed the planned simulator sessions and no adverse events such as nausea, dizziness or relevant discomfort were reported, the small sample size does not allow firm conclusions regarding tolerability or acceptance in larger and more diverse learner populations. Addressing these limitations we plan future studies with larger cohorts and objective performance endpoints to determine the true educational and clinical impact of this VR LLETZ simulator.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this preliminary validation study, we developed and evaluated a novel, open-source virtual reality simulator specifically designed for LLETZ training. The system combines realistic colposcopic visualization, real-time tissue cutting and automated performance metrics to provide an immersive and structured learning environment. Expert colposcopists rated the simulator favourably with regard to face and content validity, particularly for understanding procedural workflow, hand\u0026ndash;eye coordination and cutting precision. Usability was likewise judged to be high, with low PSSUQ scores across all domains, indicating that the system can be learned and used efficiently even by clinicians without prior VR experience. These findings suggest that VR-based training may represent a useful complement to existing LLETZ teaching formats. At the same time, the more moderate ratings for instrument handling and tissue behaviour underline the need for further technical refinement. If these aspects can be improved and the effects on clinical performance confirmed in larger studies, this VR LLETZ simulator may contribute to safer, more standardized and ethically acceptable training pathways in the management of cervical intraepithelial neoplasia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLLETZ: large loop excision of the transformation zone\u003c/p\u003e\n\u003cp\u003eHSIL: high-grade squamous intraepithelial lesions\u003c/p\u003e\n\u003cp\u003eCIN: cervical intraepithelial neoplasia\u003c/p\u003e\n\u003cp\u003e3D: three-dimensional\u003c/p\u003e\n\u003cp\u003eAR: augmented reality\u003c/p\u003e\n\u003cp\u003eVR: virtual reality\u003c/p\u003e\n\u003cp\u003eXR: extended reality\u003c/p\u003e\n\u003cp\u003eSDF: signed distance fields\u003c/p\u003e\n\u003cp\u003eCSG: constructive solid geometry\u003c/p\u003e\n\u003cp\u003eUI: user interface\u003c/p\u003e\n\u003cp\u003eIPD: interpupillary distance\u003c/p\u003e\n\u003cp\u003eLTS: long term support\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Conceptualization: Anne Cathrine Scherer-Quenzer, Matthias Kiesel and Ute Trapp, Initial VR prototype demo and manuscript editing: Adam Kalisz,\u0026nbsp;Methodology: Ute Trapp, Benjamin Meyer, Writing - original draft preparation: Anne Cathrine Scherer-Quenzer, Matthias Kiesel and Ute Trapp, Writing - review and editing: Johanna Buechel, Bettina Blau-Schneider, Quirin Notz, Supervision: Achim Woeckel. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDTR Medical (Swansea Enterprise Park, 17 Clarion Cl, Llansamlet, Swansea SA6 8RF, United Kingdom) provided the study group with two identical models of their commercial simulator LLETZlearn®\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was registered with the Institutional Review Board (Ethics Committee, Faculty of Medicine, University of Wuerzburg) (Ref. No. 2025-429-ka) and approved by the ethics committee of Faculty of Medicine, University of Wuerzburg.\u0026nbsp;Participation in this study was voluntary. All participants were informed about the purpose and procedures of the study and provided written informed consent before participating.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 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PMID: 38837238.\u003c/li\u003e\n\u003cli\u003eKiesel M, Beyers I, Kalisz A, W\u0026ouml;ckel A, L\u0026ouml;b S, Schlaiss T, Wulff C, Diessner J. Evaluating a novel 3D printed model for simulating Large Loop Excision of the Transformation Zone (LLETZ). 3D Print Med. 2022 Jun 8;8(1):15. doi: 10.1186/s41205-022-00143-x.\u003c/li\u003e\n\u003cli\u003eCostello DM, Huntington I, Burke G, Farrugia B, O\u0026apos;Connor AJ, Costello AJ, Thomas BC, Dundee P, Ghazi A, Corcoran N. A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education. J Robot Surg. 2022 Aug;16(4):749-763. doi: 10.1007/s11701-021-01302-8. \u003c/li\u003e\n\u003cli\u003eIsmail FW, Ajani K, Baqir SM, Nadeem A, Qureshi R, Petrucka P. Challenges and opportunities in the uptake of simulation in healthcare education in the developing world: a scoping review. MedEdPublish (2016). 2024 May 24;14:38. doi: 10.12688/mep.20271.1. \u003c/li\u003e\n\u003cli\u003eK. Cheng, \u0026ldquo;Reflection on the application of vr technology in the teaching of gynecological surgery for regular trainees,\u0026rdquo; Journal of Higher Education Research, vol. 4, p. 48, 04 2023.\u003c/li\u003e\n\u003cli\u003eS. S. Lie, N. Helle, N. V. Sletteland, M. D. Vikman, and T. Bonsaksen, \u0026ldquo;Implementation of virtual reality in health professions education: Scoping review,\u0026rdquo; JMIR Med Educ, vol. 9, p. e41589, Jan 2023. [Online]. Available: https://mededu.jmir.org/2023/1/e41589\u003c/li\u003e\n\u003cli\u003eAggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg. 2007 Nov;246(5):771-9. doi: 10.1097/SLA.0b013e3180f61b09.\u003c/li\u003e\n\u003cli\u003eSun P, Zhao Y, Men J, Ma ZR, Jiang HZ, Liu CY, Feng W. Application of Virtual and Augmented Reality Technology in Hip Surgery: Systematic Review. J Med Internet Res. 2023 Mar 10;25:e37599. doi: 10.2196/37599.\u003c/li\u003e\n\u003cli\u003eUniversity of Applied Sciences Darmstadt. \u003cem\u003eVR-Koni-Trainer\u003c/em\u003e. V. 1.0.9. Released 2026. https://gitlab.com/darmstadt-university-of-applied-sciences-trapp/vr-koni-trainer.\u003c/li\u003e\n\u003cli\u003eTechnologies, Unity. \u0026ldquo;Unity - Manual: OpenXR Plugin.\u0026rdquo; Accessed January 19, 2026. https://docs.unity3d.com/6000.3/Documentation/Manual/com.unity.xr.openxr.html.\u003c/li\u003e\n\u003cli\u003eSansone, Lucia Grazia, Ronny Stanzani, Mirko Job, Simone Battista, Alessio Signori, and Marco Testa. \u0026ldquo;Robustness and Static-Positional Accuracy of the SteamVR 1.0 Virtual Reality Tracking System.\u0026rdquo; \u003cem\u003eVirtual Reality\u003c/em\u003e 26, no. 3 (2022): 903\u0026ndash;24. https://doi.org/10.1007/s10055-021-00584-5.\u003c/li\u003e\n\u003cli\u003eSloan, S. W. \u0026ldquo;A Fast Algorithm for Constructing Delaunay Triangulations in the Plane.\u0026rdquo; \u003cem\u003eAdvances in Engineering Software (1978)\u003c/em\u003e 9, no. 1 (1987): 34\u0026ndash;55. https://doi.org/10.1016/0141-1195(87)90043-X.\u003c/li\u003e\n\u003cli\u003eWilpert, Dennis. \u0026ldquo;Mesh Creation and Manipulation of Existing Mesh Objects in a Virtual Reality Environment.\u0026rdquo; Master\u0026rsquo;s thesis, University of Applied Sciences Darmstadt, 2024.\u003c/li\u003e\n\u003cli\u003eReschke, Fabian. \u0026ldquo;Verwendung von Constructive Solid Geometry Zum Ausschaben von Volumen Aus Oberfl\u0026auml;chenmeshes.\u0026rdquo; Bachelorarbeit, University of Applied Sciences Darmstadt, 2025. https://gitlab.com/darmstadt-university-of-applied-sciences-trapp/vr-koni-trainer/-/blob/main/publications/Verwendung-von-Constructive-Solid-Geometry-zum-Ausschaben-von-Volumen-aus-Oberflaechenmeshes.pdf?ref_type=heads.\u003c/li\u003e\n\u003cli\u003eTakacs FZ, Radosa JC, Gerlinger C, Findeklee S, Juhasz-B\u0026ouml;ss I, Solomayer EF, Hamza A. Introduction of a learning model for type 1 loop excision of the transformation zone of the uterine cervix in undergraduate medical students: a prospective cohort study. Arch Gynecol Obstet. 2019 Mar;299(3):817-824. doi: 10.1007/s00404-018-5019-7. \u003c/li\u003e\n\u003cli\u003ehttps://docs.unity3d.com/6000.3/Documentation/Manual/ui-systems/introduction-ui-toolkit.html\u003c/li\u003e\n\u003cli\u003eVella PV. A simple trainer for the loop electrosurgical excision procedure. Aust N Z J Obstet Gynaecol. 2002 Aug;42(3):289-91. doi: 10.1111/j.0004-8666.2002.00289.x.\u003c/li\u003e\n\u003cli\u003eWilson EB, Beckmann MM, Hewett DG, Jolly BC, Janssens S. Evaluation of a Low-Fidelity Surgical Simulator for Large Loop Excision of the Transformation Zone (LLETZ). Simul Healthc. 2017 Oct;12(5):304-307. doi: 10.1097/SIH.0000000000000242.\u003c/li\u003e\n\u003cli\u003eRezniczek GA, Severin S, Hilal Z, Dogan A, Krentel H, Buerkle B, Tempfer CB. Surgical performance of large loop excision of the transformation zone in a training model: A prospective cohort study. Medicine (Baltimore). 2017 Jun;96(23):e7026. doi: 10.1097/MD.0000000000007026.\u003c/li\u003e\n\u003cli\u003eSeymour NE, Gallagher AG, Roman SA, O\u0026apos;Brien MK, Bansal VK, Andersen DK, Satava RM. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002 Oct;236(4):458-63; discussion 463-4. doi: 10.1097/00000658-200210000-00008.\u003c/li\u003e\n\u003cli\u003eLarsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, Schroeder TV, Ottesen BS. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ. 2009 May 14;338:b1802. doi: 10.1136/bmj.b1802. Erratum in: BMJ. 2009;338. doi: 10.1136/bmj.b2074.\u003c/li\u003e\n\u003cli\u003eLarsen CR, Oestergaard J, Ottesen BS, Soerensen JL. The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1015-28. doi: 10.1111/j.1600-0412.2012.01482.x.\u003c/li\u003e\n\u003cli\u003eVitale SG, Caruso S, Vitagliano A, Vilos G, Di Gregorio LM, Zizolfi B, Tesarik J, Cianci A. The value of virtual reality simulators in hysteroscopy and training capacity: a systematic review. Minim Invasive Ther Allied Technol. 2020 Aug;29(4):185-193. doi: 10.1080/13645706.2019.1625404. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"virtual reality, LLETZ, simulation, gynecology surgery, training","lastPublishedDoi":"10.21203/rs.3.rs-8882607/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8882607/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCervical intraepithelial neoplasia is commonly treated by large loop excision of the transformation zone (LLETZ), a technically demanding procedure associated with risks such as incomplete excision and cervical insufficiency. In view of patient safety and ethical concerns regarding \u0026ldquo;learning by doing,\u0026rdquo; simulation-based training is increasingly important in gynecologic education. To address the lack of a dedicated LLETZ simulator, we developed a virtual reality (VR) system specifically for LLETZ training, conceived as an open-source platform.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe central achievement of this work is a VR environment that provides a colposcopic view of the cervix, real-time tissue cutting with generation of a separate, inspectable cone specimen, and automated performance metrics. Senior consultants were invited to test the simulator to evaluate its face and content validity and its overall usefulness. Subsequently they completed a 14-item validation questionnaire and the 16-item Post-Study System Usability Questionnaire Short (PSSUQ-Short).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFace validity was rated favourably for target anatomy and overall realism, whereas instrument handling and tissue response received more moderate scores. Content validity and educational value were judged positively, with high ratings for understanding procedural workflow, hand\u0026ndash;eye coordination and cutting precision, and willingness to integrate the simulator into structured curricula. Usability ratings were likewise favourable across all PSSUQ domains.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis pilot study demonstrates the successful design of a VR-based LLETZ simulator that is feasible and educationally meaningful for training gynecology residents, and provides a promising foundation for further open development and optimisation.\u003c/p\u003e","manuscriptTitle":"A novel virtual reality-based simulator for training in LLETZ procedures: Development and preliminary validation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 21:34:08","doi":"10.21203/rs.3.rs-8882607/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-09T14:19:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84030390975029026537659865492312166326","date":"2026-04-08T08:41:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265470848944653365179885956915842543979","date":"2026-04-03T10:21:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260595971356794318370415054765097282979","date":"2026-03-30T07:59:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T00:40:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-18T10:59:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-18T03:36:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-18T03:36:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-02-14T21:35:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f58da807-0339-494c-88fb-e43a163c2279","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T21:34:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 21:34:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8882607","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8882607","identity":"rs-8882607","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}